Provider Demographics
NPI:1912416876
Name:LIFESCRIPT PHARMACY PLLC
Entity Type:Organization
Organization Name:LIFESCRIPT PHARMACY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIMONNE
Authorized Official - Middle Name:COIMBRA
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:832-549-3935
Mailing Address - Street 1:5670 38TH AVE S UNIT A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-9051
Mailing Address - Country:US
Mailing Address - Phone:701-205-4545
Mailing Address - Fax:701-205-0305
Practice Address - Street 1:5670 38TH AVE S UNIT A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-9051
Practice Address - Country:US
Practice Address - Phone:701-205-4545
Practice Address - Fax:701-205-0305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-23
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPHAR5673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1474535Medicaid